I Am Interested In Feeling Young Again
Depke Wellness New Client Application
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
What are your three biggest health challenges? *
Your answer
What are three health goals you would like to achieve in the next 12 months? *
Your answer
Do you have support from your spouse or family members in regard to your health? *
How long have you been challenged with your health issues? *
Your answer
Have you ever worked with a Holistic Wellness Center in the past?
If you have worked with another Holistic Wellness Center, which one(s) and where are they located.
Your answer
Which other avenues have you turned to in order to address your health challenges? Ex: MD, DC, acupuncture, massage, nutritionist, etc.
Your answer
Please list all laboratory testing you have had completed with regard to your health challenge including testing dates. Ex: blood, saliva, stool, etc.
Your answer
Are you willing to make lifestyle changes to improve your health? *
Do you realize that overcoming your health challenge(s) would be an investment of time and money? *
Do you need to fit your holistic care into a budget? *
Do you feel as if you have the time and energy to commit to your health and happiness? *
Are you comfortable with phone or Skype consultations or do you prefer face to face consultation? *
Are you willing to take responsibility for your health challenges and follow a customized protocol to improve your health? *
Your progress will be dependent on your current state of health, the length of time your health has been challenged and other factors. While you may feel some significant improvements relatively quickly, do you realize that addressing your health holistically will take perhaps six to 12 months or more? *
Were you referred you to the Depke Wellness Center? *
If so, who referred you?
Your answer
Briefly describe why you feel the Depke Wellness Center would be a good fit for you.
Your answer
Thank you for submitting your application! Once it is reviewed we will contact you about your qualification status. If you qualify, the next step is to schedule a 20 minute phone or in office consultation to explain the Depke Wellness Process to feeling young again. We do require a $75.00 application deposit that is refundable under the following circumstances: 1. When you choose to move forward with the Depke Wellness Center your deposit will be applied to your next purchase. 2. If you decide not to move forward, your application fee will be fully refunded. 3. If you do not qualify at this time, your application fee will be fully refunded. 4. Lastly, if you do not complete your scheduled 20 minute consultation, you agree to relinquish your $75.00 deposit. *
Please type your name as your electronic signature for this application. *
Your answer
Please note today's date. *
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